Cystometry: Dr. Abdelazim Hussein Khalafalla Ass - Professor Urology Department National Ribat University

Cystometry
Dr. Abdelazim Hussein Khalafalla

Ass . Professor
Urology Department
National Ribat University
Cystometery
Filling cystometry Voiding cystometery
Ability to store Efficacy of

Emptying
Filling Cystometry
• Measures the pressure/volume relationship of

the bladder (Measurement of detrusor pressure
during controlled bladder filling)
• filling medium either gas (CO2) or liquid
(water, saline, or contrast material at body
temp).
• liquid cystometry is more physiologic.
• ideally, filling should be performed in standing
position.
Detrusor pressure
• Cannot be measured
• It is estimated/calculated by the automatic
subtraction of rectal pressure (an index of IAP)
from the total bladder pressure, thus removing
the influence of artefacts produced by
abdominal straining
Pdet = Pves - Pabd
Filling Cystometry
Failure to store
Bladder Outlet
1. Overactivity 1. ISD
2. hypermobility
2. hypersensitivity
3. Combination
Filling Cystometry: Aim
Used to assess
1. Bladder sensation,
2. Detrusor activity,
3. Bladder capacity,
4. Bladder compliance,
5. Outlet incompetence.
Filling Cystometry: Technique
• Patient preparation:
History and Examination
MUS
Explain the procedure
Voiding
Catheterization
Measure the residual urine
• Patient may be investigated supine, sitting or
standing.
• The transducers are calibrated.

• Zero setting.
• Connect the catheter to the cystometer.
• Start recording and infusion.
• Instruct the patient to report (FD), strong
desire to void, urgency, cystometric bladder
capacity (CBC)
• The patient is asked to cough every minute during filling and

after voiding to ensure that the catheters have not become
displaced during micturition.
• If the spikes are not identical, lower traces, then the
explanation maybe :
– There are bubbles or
– Leaks,
– Catheters are mal-positioned
– Interference with the measurement of pabd due to faecal loading.
• All these points must be checked and the cough repeated until
the proper pattern is observed.
Pabd
Pves
Vinfus
Filling
Bladder
Recording
Bladder Pressure
Reaction
Pump during Filling
Pves With Control of
Pabd Abdominal Pressure
Pressure
Transducers
Pves
Pressure
Transducer
P ves
Proximal
Filling Line
Peristaltic Pump
Filling Cystometry: Out Put
• Curves (Traces)
• Results (Table)
• Report (Word)
Filling Cystometry: Results
Events Pdet Volume Compliance

cmH2O ml ml/cmH2O
Basic Pressure BP 3 20
First Desire FD 7 160 35
Normal Desire ND 12 270 22
Strong Desire SD 21 440 19
Urgency UR 30 575 15
Max Cysto. Capacity CC 32 610 20 18
Filling Cystometry: Traces interpretation
Principles
• If a change is seen in both Pves and Pabd but not in
Pdet, then it is due to raised IAP.
• If a pressure change is seen on Pves and Pdet and not
on Pabd, then it is due to a detrusor contraction.
• If a change is seen on Pves, Pabd and Pdet, then
there is both a detrusor contraction and raised IAP.
• If a pressure change is seen on pabd with no change
in pves and a consequent fall in pdet then this due to
a rectal contraction.
Post void residual urine

• Post void residual urine above 300 ml, who have a
pressure Rise at end pressure above 25-30 cm H2O,
carry a risk of more than 50% of developing
dilatation of the upper urinary tract.
• In-and-out catheterization has been regarded as the
gold standard.
• Transabdominal ultrasonography is non-invasive and
the method of choice, based on calculations using
different formulas (an example is 0.5 x length x
height x width of the bladder).
Pitfalls of PVU
• A delay time between voiding and measurement is the most
frequent cause of a false positive
• Voiding in unfamiliar surroundings,
• Voiding on command,
• A partially filled or overfilled bladder,
• Vesicoureteric reflux
• Bladder diverticula,
• Inproper catheter emptying technique,
1-Bladder sensation
• In a normal bladder, first desire often occurs at
a bladder volume of 100-400 ml, depending on
the filling rate, position and catheter used.
• FD < 100 --- Bladder hypersensitivity
• FD > 400 --- Patient never experiencing a
strong desire to void -------Reduced sensation
• Absent sensation ----indicative of a neurological

condition such as spinal cord trauma
2-Detrusor Activity
The normal detrusor remains quiescent during
filling and detrusor overactivity does not occur under
any circumstances (e.g., during the provocation
tests(Provocative Cystometry) used in an effort to
uncover detrusor overactivity (DO))
Provocative Cystometry
Provocative cystometry involves a series of triggering
procedures aiming to elicit reflex detrusor activity.
Physical Provocation
-Rapid bladder filling (>100 ml/min),
-Jumping up and down ,
-Coughing,
-leaning forward,
- changing posture (from supine to sitting or
standing),
-Crede maneuver (suprapubic tapping) may help trigger unstable
detrusor contractions.
3-Bladder capacity,
• The normal bladder capacity is in the range
of 300 to 500 mL;
• Cystometric bladder capacity (CBC) if the
resting pressure reaches 30 cm H2O
• In infants and in some neuropathies CBC can
be taken as the volume at which the patient
starts voiding.
4-Compliance:
• Normal bladder is highly compliant, and can hold
large volumes at low pressure.
• Compliance is the change in volume divided by the
change in detrusor pressure during that change in
bladder volume and is expressed as ml/cm H2O
(C = Vol / pdet). 12-29 ml/cmH2O
• Normal pressure rise during the course of CMG in
normal bladder will be only 6-10 cmH2o.
• Normal values of bladder compliance have not
been well defined.
• Decrease compliance = > 20 ml/cmH2o,
poorly distensible bladder.
• suggested that the lower limit of normal in
• women was >40ml/cmH2O
? Increase compliance
- competent
- incompetent
Voiding Cystometry
EMG
Pabd
Pves
Qura
Pves Recording
Bladder Pressure
Pabd Abdominal Pressure
EMG
Electromyography
during
Qura Voiding Phase
Voiding Cystometry
Patient
In sitting position
Ask the patient to void without straining
Equipment
Transducers Bladder level
Sweep Speed 10 sec./Div.
Pressure Sensitivity 20 cmH2O/Div.

Flow rate Sensitivity 5 ml/sec.
EMG Sensitivity 10 µV/Div.
VOIDING CYSTOMETRY. Normal
Low EMG activity
during voiding =
EMG Synergy
Pves
No Abdominal
Pabd Pressure
Normal Detrusor
Pdet Pressure
Normal Flow Rate

Qura & duration
Vura
QM
PM
VB
VE
Time 10 sec/Div
Voiding Cystometry. DSD
EMG
Pves
Pabd
Pdet
Qura
QM
PM
VB
VE
Vura
Time 1 min/Div
C FS ND S D UR CC
Normal filling cyst

FS UR ND SD
Increased BL sensation Reduced sensation
Absent sensation
1. Sensation “sensation against volume”
No involunatry det contration
2. Detrusor function
Pdet 60
Terminal DO
Phasic DO
No increase
in Pdet
500
CC
3. Compliance
Steady increase Det P
250
low compliance
CC
4. Cystmetic bladder capcity

DOV Decreased compliance hypersensitivity
Decrease Max CC
Urgency, frequency, nocturia

Leak
Each Phasic DO
U U
Phasic detrusor overactivity incontinence

Involuntary voiding
Terminal
Involuntary DO
Terminal detrusor overactivity incontinence

Involuntary voiding
Terminal
Involuntary DO
Terminal detrusor overactivity incontinence

No increase Det P
leak
Urodynamic Stress incontinence

No increase Det P
leak
Urodynamic mixed incontinence

Pabd
Pves
Pdet
Cystometry trace showing the patient straining (S), a cough superimposed on

an involuntary detrusor contraction (C + U) and an involuntary detrusor
contraction (U).
Pves
Pabd
Pdet
Rectal contraction: characterised by a positive wave on

the pabd trace and a negative artefact on the pdet trace.
Pitfalls in Cystometry
Causes of artifact in cystometry

1. Pressure measurement artifacts
Air bubbles,
Kinked tubing,
Incorrect placement of the pressure catheters,
Migration of the pressure catheters
2. Infusion rate artifacts (especially in neurogenic
bladder)
3. Patient-related issues,
Lack of cooperation,
Outlet incompetence,
Vesicoureteral reflux .
Report Writing
• Click on report icon.
• Word sheet will be displayd.
• Fill data on the space.
• Using the traces & result write down :-
1. Bladder sensation,
2. Detrusor activity,
3. Bladder capacity,
4. Bladder compliance,
6. PVU.

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Cystometry

Dr. Abdelazim Hussein Khalafalla

Filling cystometry Voiding cystometery

Ability to store Efficacy of

• Measures the pressure/volume relationship of

• The transducers are calibrated.

• The patient is asked to cough every minute during filling and

Events Pdet Volume Compliance

Post void residual urine

• Absent sensation ----indicative of a neurological

Pressure Sensitivity 20 cmH2O/Div.

Normal Flow Rate

Normal filling cyst

Increased BL sensation Reduced sensation

4. Cystmetic bladder capcity

Urgency, frequency, nocturia

Phasic detrusor overactivity incontinence

Terminal detrusor overactivity incontinence

Terminal detrusor overactivity incontinence

Urodynamic Stress incontinence

Urodynamic mixed incontinence

Cystometry trace showing the patient straining (S), a cough superimposed on

Rectal contraction: characterised by a positive wave on

Causes of artifact in cystometry

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